"Doctors' Dissatisfaction With EHRs May Be Early Warning of Deeper Quality Problems" - And Some Common Sense on EHRs and Clinician Distraction and Time-Wasting

The following article was published regarding physician dissatisfaction with EHRs, referencing a RAND study on EHRs commissioned by the American Medical Association:

http://cnsnews.com/news/article/susan-jones/doctors-dissatisfaction-ehrs-may-be-early-warning-deeper-quality-problems-0

Doctors' Dissatisfaction With EHRs May Be 'Early Warning of Deeper Quality Problems'
October 18, 2013 - 10:17 AM
By Susan Jones

Electronic health records (EHRs) are a source of frustration to many physicians, says a new study conducted by the RAND corporation and commissioned by the American Medical Association.

Electronic health records are a source of frustration to many physicians, according to a study on physician satisfaction sponsored by the American Medical Association.

The findings could serve as an "early warning of deeper quality problems developing in the health care system," the AMA said.

The study, conducted for AMA by the RAND Corporation, found that doctors who perceived themselves or their practices as providing high-quality care reported better professional satisfaction.

Electronic health records (EHRs) were a source of both promise and frustration, the Rand study found.

Although physicians tend to like the concept of EHRs, those surveyed said that current EHR technology interferes with face-to-face discussions with patients; requires physicians to spend too much time performing clerical work; and degrades the accuracy of medical records by encouraging template-generated doctors' notes.

I believe the title should have been "Doctors' Dissatisfaction With EHRs Is A Warning of Deeper Quality Problems".  The academic-style fudge words "may be" and "early" are disposable.

"Physicians [i.e., all of them - ed.] believe in the benefits of electronic health records, and most do not want to go back to paper charts," said Dr. Mark Friedberg, the study's lead author and a RAND scientist. "But at the same time, they report that electronic systems are deeply problematic in several ways. Physicians are frustrated by systems that force them to do clerical work or distract them from paying close attention to their patients."

Dr. Friedberg commits a faux pax symptomatic of an amateur scientist (or of a politician).  That is, making a statement that seems to speak for all physicians, and then for "most" physicians.  Clearly he didn't interview "most" physicians.  I know many who see the EHR as bureaucratic invasion of little clinical utility, and would gladly dump the poorly-engineered EHRs foisted on them that "interfere with face-to-face discussions with patients; require physicians to spend too much time performing clerical work; and degrade the accuracy of medical records" for good old-fashioned paper, supplemented perhaps with document imaging systems that make the notes available anywhere, anytime.

... Health and Human Services Secretary Kathleen Sebelius has said that EHRs will lead to "more coordination of patient care, reduced medical errors, elimination of duplicate screenings and tests, and greater patient engagement in their own care."

Sebelius is parroting others; there is little or no robust evidence supporting such a grandiose assertion (or, typical of today's politicians, she's simply lying; the reader can decide which).

For 2014, some commonsense observations and recommendations on EHRs:

1) The pioneers in the 1950's and 1960's developed systems and experimented with their use in an environment far freer of the bureaucratic need for massive amounts of ultra-taxonomized data than today, where visits were not forced to be time-limited for "productivity", and where clinical notes were pithy and terse, as they were for patient care, not bureaucratic satiation.  The pioneers likely could not have conceived of what clinicians are being called on to enter manually, in 2014.  (I was taught Medical Informatics by some of those pioneers.)

2) The pioneers never intended to add uncompensated burdens onto clinicians.  They intended to help clinicians practice medicine more smoothly, not in a time-starved and robotic, slave-to-the-machine fashion.

3) The health IT industry and its health IT designers, and the largely medically-incompetent data processing/merchant computing personnel in hospital IT departments, appear to have not cared less about these real-world HIT issues - as evidenced by their products - until the pressure was put on by users, resulting in studies of IT safety by the Institute of Medicine (http://hcrenewal.blogspot.com/2010/10/cart-before-horse-again-institute-of.html) and of IT usability by NIST (http://hcrenewal.blogspot.com/2010/12/nist-provides-healthcare-it-industry.html) in just the past few years.

With these factors in mind:

... AMA noted that some medical practices are experimenting with ways to reduce physician frustration by hiring additional staff members to perform many of the tasks involved in using electronic records, such as data entry.

Actually, the use of clinicians as computer data-entry clerks was the real experiment, an experiment whose failure is becoming increasingly apparent. 

The "experiments" with hiring of data entry clerks should be made official healthcare policy as follows: 

1)  Physicians and nurses should be relieved of the burden of data entry into computer interfaces (as opposed to merely viewing) nearly entirely.  Data entry cannot be done under the real-world conditions of patient care in 2014, for most specialties, without compromising the focus on patient care (let alone clinician morale).  

2) Considering the hundreds of millions per organizations spent on theses systems, a pool of data entry clerical staff can well be afforded, hired and trained to transcribe data into computers from clinicians' paper notes, using specialized forms where necessary.  

3) Those same paper notes can be rapidly imaged into a document management system (e.g., Documentum, http://www.emc.com/enterprise-content-management/documentum-platform.htm; I managed a pharmaceutical department of ~55 people and a $13 million budget using such a system) and made available before transcription.  The note images can also serve as a supplement to data viewing screens in the EHR, which at least in 2014 are themselves poorly engineered from the perspective of optimal presentation of information.

4) The workflows for such arrangement are known to me; I created such an environment in a busy invasive cardiology department, a critical care area performing more than 6000 procedures/year and responsible for 25% of the organization's revenues - fortunately having been able to neutralize and marginalize an IT department seemingly hellbent, perhaps through ignorance, on sabotaging the effort.  See "Essential Value of Medical Informatics Expertise in High-Risk Areas: an Invasive Cardiology Example" at http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story.  The offloading of data entry by clinicians into the computer, and the use of special paper forms for the clinicians, worked exceptionally well in allowing the clinicians to focus on what really matters most - patient care.

5) If healthcare organizations insist on direct clinician data entry, then clinicians' time doing so should be fairly compensated.  Lawyers generally earn from $250/hr and up for profession-related clerical work, like creating legal briefs and letters.  I think physicians should do at least as well.  (If readers believe clinicians should take on this considerable burden and not be fairly compensated, I'd like to hear why.)

6) If healthcare organization leaders truly believe the EHR hyper-enthusiasts, the expense of the clericals will be far offset by the "billions and billions" saved by these systems.

       a) If they don't believe the EHR hyper-enthusiasts, they should be far more skeptical of implementing such systems and imposing the mission-robbing burdens on their clinicians in the first place.

7) These measures will free industry resources for doing what really matters most in clinical care, namely, health IT robustness (freedom from error, security, etc.) and optimal presentation of information customized for the needs of the many different clinical specialties and subspecialties.

-- SS

American Medical Association finally on board with EHR views expressed on this blog since 2004

- Posted on the Healthcare Renewal Blog May 17, 2013 -

It seems to have taken awhile, but organized medicine seems to finally be recognizing that today's commercial health IT is not quite the revolutionizing, transformative, plug-and-play panacea to healthcare's ills it is often touted as:

AMA Wire
May 15, 2013
AMA board chair: HHS should address EHR usability issues immediately

The government needs to act quickly to remedy the impaired usability of electronic health records (EHR) if the technology's touted benefits are to be realized, AMA Board of Trustees Chair Steven J. Stack, MD (left), told officials during a federal hearing last week.

"The AMA and most physicians believe that, done well, EHRs have the potential to improve patient care," Dr. Stack, an emergency physician in Lexington, Ky., said during his 30-minute testimony. "At present, however, these EHRs present substantial challenges to the physicians and other clinicians now required to use them."

He emphasized that many of today's EHR systems require significant changes before they can deliver the promised outcomes. Referring to Medicare's meaningful use program, he pointed to undesired consequences of pushing EHR systems on physicians before the technology was completely ready for prime time.

"Immediately" is strong language.

I note that the phrase "health IT done well" is a term I've been using since 1998 at my now-Drexel-based health IT teaching website at http://www.ischool.drexel.edu/faculty/ssilverstein/cases, as well as at this blog.

Penned by me at my aforementioned Drexel graduate teaching site, originally housed on AOL, in 1998 and still appearing in its main essay:

... While clinical IT is now potentially capable of achieving many of the benefits long claimed for it such as improved medical quality and efficiency, reduced costs, better medical research and drugs, earlier disease detection, and so forth, there is a major caveat and essential precondition:  the benefits will be realized only if clinical IT is done well.  For if clinical IT is not done well, as often occurs in today’s environment of medical quick fixes and seemingly unquestioning exuberance about IT, the technology can be injurious to medical practice and biomedical R&D, and highly wasteful of scarce healthcare capital and resources. 

Those two short words “done well” mask an underlying, profound, and, as yet, largely unrecognized (or ignored) complexity.  This website is about the meaning of "done well" in the context of clinical computing, a computing subspecialty with issues and required expertise quite distinct from traditional MIS (management information systems, or business-related) computing.

(I have more recently switched to the easier-to-parse terminology of "good health IT" vs. "bad health IT" after discussions with Dr Jon Patrick at U. Sydney during my visit Down Under last summer, http://hcrenewal.blogspot.com/2012/08/my-presentation-to-health-informatics.html.)

I've also heard "not ready for prime time" before.  It is a phrase I used in speaking with a New York Times reporter that then appeared in the Oct. 8, 2012 NYT article "The Ups and Downs of Electronic Medical Records" (http://www.nytimes.com/2012/10/09/health/the-ups-and-downs-of-electronic-medical-records-the-digital-doctor.html?pagewanted=2) by Milt Freudenheim, October 8, 2012, where I am quoted and this blog cited:

... Critics are deeply skeptical that electronic records are ready for prime time. “The technology is being pushed, with no good scientific basis,” said Dr. Scot M. Silverstein, a health I.T. expert at Drexel University who reports on medical records problems on the blog Health Care Renewal. He says testing these systems on patients without their consent “raises ethical questions.”

The AMA Board chair went on to opine:

"Attempting to transform the entire health system in such a rapid and proscriptive manner has compelled providers to purchase tools not yet optimized to the end-user's needs and that often impeded, rather than enable, efficient clinical care," he said.

He noted that physicians are "prolific technology adopters" but that adoption of EHR systems has required federal incentives because the technology still is "at an immature stage of development."

My near-exact terminology has been that the technology is still experimental.

"EHRs have been and largely remain clunky, confusing and complex," he said.

Perhaps he read my ten-part series on the health IT mission hostile user experience at this blog, at http://www.tinyurl.com/hostileuserexper.

According to a recent survey by AmericanEHR Partners, physician dissatisfaction with EHR systems has increased. Nearly one-third of those surveyed in 2012 said they were "very dissatisfied" with their system, and 39 percent said they would not recommend their EHR system to a colleague—up from 24 percent in 2010.

A survey I posted about in Jan. 2010 is here:  "An Honest Physician Survey on EHR's", http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html

Dr. Stack spoke at a "listening session" hosted by the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC), a division of the U.S. Department of Health and Human Services (HHS). The agencies coordinated the session to examine how a marked increase in code levels billed for some Medicare services might be tied to the increased use of EHRs.

Dr. Stack noted that some Medicare carriers have begun denying payment for charts that are too similar to other records.

"In this instance, even when clinicians are appropriately using the EHR, a tool with which they are frustrated and the use of which the federal government has mandated under threat of financial penalty, they are now being accused of inappropriate behavior, being economically penalized, and being instructed ‘de facto' to re‐engineer non‐value‐added variation into their clinical notes," he said. "This is an appalling Catch‐22 for physicians."

"Mandated under threat of financial penalty" has been one of my stated "cart before the horse" issues with HITECH (e.g., http://hcrenewal.blogspot.com/2010/10/cart-before-horse-again-institute-of.html).

Dr. Stack advised officials that three key actions are necessary to rectify these issues with EHR systems:

• The ONC promptly should address EHR usability concerns raised by physicians and add usability criteria to the EHR certification process.
• CMS should provide clear and direct guidance to physicians concerning use of EHRs for documentation, coding and billing.
• Stage 2 of the meaningful use program should allow more flexibility for physicians to meet requirements as EHR systems are improved.

The AMA will continue to work with federal agencies to improve EHR systems and the Medicare meaningful use program.

I've been calling for usability evaluation to be added to the certification process, including in comments during public comment periods to HHS, for some time.

What the AMA Board Chair is apparently missing, though, is health IT safety.  They should perhaps read my post on the recent ECRI Institute Deep Dive Study on health IT risk - itself based on a report in their own AMNews (amednews.com) publication ("Peering Underneath the Iceberg's Water Level: AMNews on the New ECRI Deep Dive Study of Health IT Events", http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html).

I don't think any prudent person would consider a 9-week study of 36 hospitals with volunteered reports of 171 health information technology-related problems, where eight of the incidents reported involved patient harm and three may have contributed to patient deaths, information to ignore.

-- SS

AMA says EHRs create 'appalling Catch-22' for docs - And just how many experts does it take to screw in a light bulb, anyway?

(NOTE:  this post, being about minor matters like death and financial mayhem, is particularly and unusually [even for me] biting and lacking in euphemisms and political correctness.  If you are easily offended and want the latter, and/or believe we all need to be 'nice' about banal issues like patient injury and death, fraud, and other minor matters, click here:  http://www.disney.com and skip the post below.)

You were warned.

---------------------------------------

At some point, so-called EHR "experts" and pundits need to stop being accommodated for their having ignored years of warnings, complaints, "anecdotes" -a particularly egregious term that comes from those who don't understand risk management, especially academics of the echo chamber-egghead subspecies (link) - and other signs that health IT is not a beneficent, omniscient gift from the Lords of Kobol. (The latter is a pun on the business-IT programming language Cobol, of course.)

Instead, they simply need to be ridiculed for being stupid.

I will do so:  folks, you have been, and remain, stupid:

The Bovine Stare of Incomprehension (click to enlarge)

The Bovine Stare of Incomprehension describes the reactions I've gotten over the years to many warnings about health IT.  It was like talking to a cow.

So now there's this:

AMA says EHRs create 'appalling Catch-22' for docs
May 03, 2013 | Tom Sullivan, Editor

As the healthcare industry moves to EHRs, the medical record has essentially been reduced to a tool for billing, compliance, and litigation that also has a sustained negative impact on doctors' productivity, according to Steven J. Stack, MD, chair of the American Medical Association’s board of trustees.

Gee, they're only realizing and complaining about that - now?  In 2013?

“Documenting a full clinical encounter in an EHR is pure torment,” Stack said during the CMS Listening Session: Billing and Coding with Electronic Health Records on Friday.

(What, the "pure torment" in such a mission-critical function only started with the most recent patches installed last month on the nation's EHRs?  EHRs were just dandy until then?)

It's nice to know in May 2013 that “documenting a full clinical encounter [essential to avoid injurious and even lethal mistakes, I anecdotally note - ed.] in an EHR is "pure torment”, several years into an accelerated "National Program for HIT in the HHS" costing hundreds of billions of dollars.

I guess sites like this blog, this site extant since 1998, and other materials written over the years by backwards stubborn health IT iconoclast fear-mongering Luddites were beyond the comprehension level of - those now proffering the exact same pronouncements.

EHRs are also driving the industry toward charts that look remarkably similar because they’re based on templates created by the technology vendors — that includes often using the same words. And that threatens to make doctors appear to be committing fraud by the practice of record cloning, or cutting and pasting from one record to another, when they are not, in fact, acting fraudulently. 

I guess putting patients in mortal danger from note cloning (and to those too stupid to understand why that is, get off your rear end and look it up, I'm not going to spoon-feed you) is a step better than acting fraudulently...

Alongside the federal mandate to implement an EHR under threat of a monetary fine, that creates what Stack called “an appalling Catch-22 for physicians.”

Put another way: The government mandates that doctors use an EHR, the EHR vendors’ templates can sometimes create an appearance of fraud and that, in turn, opens the door for payers to decline reimbursement or, even worse, the government to prosecute doctors for the crime.

I guess actual fraud is just anecdotal.

As dire as that sounds, it's an exception that belies the unproven perception that EHRs perpetuate fraud. “Upcoding does not necessarily equate to fraud and abuse,” said Sue Bowman, AHIMA’s senior director of coding and compliance at the same event. “This is an area where more study is needed. We really need to know the causes. Further research is needed on the fraud risk of using EHRs.”

Sure, let's study while rolling this stuff out as frantically as we can.  We'll fix it later -- and Jesus, I guess, will heal and reanimate any patients actually harmed by the technology (link to ECRI Institute Deep Dive Study: 36 hospitals!  Nine weeks!  171 health information technology-related problems voluntarily reported!  Eight injuries!  Three possible deaths!  All mere "anecdotes", of course).

Indeed, Jacob Reider, MD, CMO of ONC, explained that the government and industry do not have good data right now proving whether or not EHRs trigger fraud and abuse.

Per the IOM, the same industry does not have good data on harms levels.  (The previous link to a recent small ECRI "Deep Dive" study's probably the most robust we've got on that score, and the figures are not encouraging).

So - let's review -

• poor data on harms, 
• poor data on benefits, 
• poor data on fraud and abuse.

 The logical, ethical course of action thus is:

D'OH!  LET'S ROLL THE TECHNOLOGY OUT AS FAST AS WE CAN, AND PENALIZE NON-ADOPTERS BESIDES!

See how simple logic, ethics and clear thinking can be?

“There is concern that some doctors are using the EHR to obtain payments to which they are not entitled,” said Mickey McGlynn of Siemens Medical Solutions and HIMSS EHR Association. “Any fraud is an important issue and we, as the vendor community, take that very seriously.”

Only after independent whistleblower investigations by Fred Schulte of the Center for Public Integrity ("Cracking the Codes"), and by New York Times reporters Reed Abelson and Julie Creswell, that is...

AMA’s Stack offered a triptych of suggestions to CMS and ONC: address EHR usability concerns, provide guidance on EHR use for coding and billing, and make meaningful use stage 2 more flexible for providers.

“My purpose is not to denigrate EHRs,” Stack said, explaining that he believes CMS and ONC are genuinely trying to better the current situation.

Nice to have Caspar Milquetoast  on the side of EHR criticism.

Knock knock, anyone home, McFly?

Knock knock, anyone home, McFly?

Today's EHR systems, for the aforementioned reasons above and more, deserve denigration for patients' sake.

There are efforts underway, within the government and industry, to more comprehensively understand the unintended consequences of EHR implementation.

But let's keep rollin' em out, anyway.  Wheeee!  What fun!

Class action attorneys, are you listening?

-- SS

AMA News Article Offers Incomplete (and Thus Misleading) Advice on the Legal Risks of EHRs and other Clinical IT

An article was published in the AMA News by Alicia Gallegos, AMA Medical News staff, entitled "Legal risks of Going Paperless." While it is not clear if these are the official views of the AMA leadership, the article is interesting nonetheless.

It should perhaps have been entitled "Some of the Legal Risks of Going Paperless, excluding the ones that make the health IT industry look bad:"

Legal Risks of Going Paperless
AMA News
March 5, 2012

Electronic medical records are meant to save time and money, but they also can create liability issues for doctors.

By Alicia Gallegos, amednews staff.

Defense attorney Catherine J. Flynn knows how electronic medical records can overwhelm — and often change — the course of a medical liability lawsuit.

In one of her cases, a New Jersey doctor being sued for medical negligence has been accused by a plaintiff’s attorney of modifying a patient’s electronic history. A printing glitch caused the problem, Flynn said, but the accusation has meant extra time and defense costs. Computer screen shots were reviewed, more evidence was gathered and additional arguments were made.

“This has taken a life of its own, and we’ve done virtually no discovery on the medical aspects of the case,” she said. “The cost of the e-discovery alone is in excess of $50,000.”

This is a variation on the theme of plaintiff's lawyers being the cause of EHR problems as I wrote at "Plaintiff's Trial Lawyers Are to Blame for EHRs That 'Tattle' on Doctors - And Harm Patients."

System breaches. Modification allegations. E-discovery demands. These issues are becoming common courtroom themes as physicians transition from paper to EMRs, legal experts say. Not only are EMRs becoming part of medical negligence lawsuits, they are creating additional liability.

Missing is the problem that is most important of all: health IT system defects, poor user interfaces, unreliability, data loss, etc. causing or contributing to medical malpractice that results in patient harm or death. (An example that I personally observed and reported to the FDA MAUDE database is here; there are numerous others in this blog.)

Data breaches are among the most common reasons that electronically stored information lands doctors in court, said Lisa Gallagher, senior director for privacy and security at the Health Information and Management Systems Society, which advocates health information technology

Most common perhaps (a big problem unto itself), but not the most clinically significant problem. Yet the AMA article goes on about this issue for many paragraphs; it's the prime focus of the article.

A 2011 ruling in New York highlights how e-discovery creates a burden for doctors.

During a lawsuit against St. Luke’s Hospital Roosevelt Center, a debate arose about whether the plaintiff should be allowed access to screen shots from a doctor’s computer. Joan Bowman, who sued the hospital for wrongful death on behalf of her husband, wanted to see a computer template used to aid physicians in diagnoses. The hospital said the request was overly broad and oppressive.

But the Supreme Court of the State of New York ordered the release of the screen shots.

“Defendant doctors testified that they utilized these materials in coming to their diagnosis,” Judge Alice Schlesinger wrote. “It is not a stretch to allow counsel to see and understand these materials.”

At this article’s deadline, the hospital’s attorney had not returned messages seeking comment.

The case sets a precedent, said Susan Dennehy, Bowman’s attorney.

“If others want to see screen shots from records, I think they’ll rely on this case,” she said. “It was important to see where the template led you if you put in an inaccurate chief complaint.”

Note the "spin" about the "burden for doctors" of eDiscovery. To the pundits and voluntary adopters: you have gotten what you asked for. To the non-pundit clinicians forced to use health IT: I hate to say this, but you've gotten screwed.

The article then offers a laundry list of how to avoid EHR-related liability:

... As the number of electronic medical records increases, so do certain legal risks, medical liability experts say. Common mistakes doctors make with EMRs and how attorneys recommend that physicians reduce their liability risks:

Mistake: EMRs allow users to move quickly through patient records, but cutting and pasting information makes it easy to paste incorrect information.
Recommendation: Refrain from copying and pasting EMR data, and be cautious when moving from one patient’s record to the next.

Mistake: Computer programs can help doctors make a differential diagnosis, but the templates don’t often include every possible symptom and corresponding medical condition.
Recommendation: Doctors should not become overly dependent on electronic diagnosis aids. Electronic systems are no substitute for hands-on diagnosis.

Mistake: Because EMRs allow physicians to move through patient charts much more quickly than paper charts, attorneys are noticing that some doctors are not being thorough when writing notes electronically.
Recommendation: Physicians should keep meticulous electronic notes on each patient and take time to document each chart.

Mistake: Some practices can fail to safeguard electronic patient data.
Recommendation: Practices should encrypt all information on computer devices and have policy that discourages employees from taking portable devices out of the office.

Mistake: A system may not clearly indicate changes to records.
Recommendation: Physicians should install systems that show transparency when modifications are made and/or have a program lockout period where no more modifications can be made to a record.

Mistake: Doctors may fail to follow notification requirements in the event of a data breach.
Recommendation: Be clear on what your state law requires when a data breach occurs, and make sure employees follow the rules immediately.

Mistake: Doctors may destroy or delete electronic records when a lawsuit is possible.
Recommendation: If doctors suspect they are being sued, they must preserve all electronic data related to the patient in question, including emails, phone messages and computer records.

Missing is this, as is well-covered by almost 8 years of posts on this blog, and elsewhere:

Big mistake: Doctors and hospitals buy and implement experimental technology approved by nobody, of uncertain quality to the point of losing or corrupting data, often with glass-tube black-and-white TV user interface modernity. Such technology is "errorgenic", i.e., it promotes "use error", can mislead, and can promote medical errors.
Recommendation: Hold off until the industry has gotten its act together.

Also missing from the AMA News article is the fact that physicians and hospitals use health IT at their own risk, even if the IT is "certified."

This article is clearly pregnant with omissions and spin that reveal a pro-health IT bias.

-- SS

Three Golden Parachutes and Some Unexpected Sequels

Golden parachutes are an always fascinating aspect of executive compensation in health care.  I have collected three relatively recently revealed stories about golden parachutes given to government and non-profit hospital system CEOs, at least two of which involve unexpected, and also fascinating sequels.  They will appear in order of the apparent size of the parachutes.

Santa Clara Valley Health and Hospital System

Santa Clara Health and Hospital System is a county (government) system of moderate size in California.  Last week, the compensation given its outgoing CEO in 2010 was revealed by the San Jose Business Journal:

Former Santa Clara Valley Health and Hospital System CEO Kim Roberts walked away with an impressive chunk of change when she abruptly left the job in February 2010.

According to a city and county salary report released from the State Controllers Office, the position earned a little over $1 million that year.

A county spokeswoman confirmed that the total included accrued vacation, sick leave and other payments Roberts was entitled to.

The salary was the highest in the Bay Area for public employees in 2010.

Note that

Roberts was hired as CEO in March 2007 with a five-year contract. The agreement included a starting salary of $285,744 with annual salary adjustments, severance and other benefits.

The issue here is that Ms Roberts was the CEO of a local government run health system. Traditionally, the pay given to people in such positions is closely scrutinized by politicians and tax payers, and hence is usually less than that given out by private, non-profit hospital systems, much less for-profit ones. Nonetheless, while it appears that Ms Roberts got something more than $700,000 worth of compensation beyond her usual salary in her last year, the nature of this compensation, and the justification for it is unclear.

Erlanger Health System

The story that got my attention appeared two days ago in the Chattanooga Times-Free Press:

After more than a month of negotiations, Erlanger trustees reversed a previous vote and approved a controversial $728,000 severance package for outgoing CEO Jim Brexler.

Trustees voted 4-4 against the same severance package in December but voted 5-4 to approve it during a 30-minute meeting Monday morning.

More detail about the package:

The approved agreement provides 15 months of severance for Brexler, worth about $713,000. He also keeps his Erlanger health coverage for 18 months, paying his employee portion, a benefit worth about $15,000.

This story is actually a complex sequel. We discussed CEO compensation at Erlanger Health System, an academic medical center affiliated with the University of Tennesse, a year ago. At that time, we noted that a substantial bonus given to then CEO Jim Brexler was based on favorable financial results in the previous year, but did not apparently take into account the more recent decline in the system's finances. That bonus was justified by the typical paean to the leadership's "real expertise in health care" by one member of its board.

By last month, however, Erlanger's finances had deteriorated dramatically. A Free Press article then stated,

Erlanger hospital employees have been asked to take 12 days off in the next two months, consider voluntary buyouts and face possible layoffs as Chattanooga's only public hospital bleeds money.

The hospital has lost more $6 million in the last five months, half of that in November.

The reason for this accelerating misfortune deterioration remain unexplained. Apparently, CEO Brexler had decided to depart, for also unclear reasons, two months earlier:

In October, the hospital announced CEO Jim Brexler would retire at the end of the year.

At that time, the board had voted to give him the severance package described above, but then suddenly began to reconsider after how bad things were became clear:

The board voted earlier this month not to give Brexler a more than $700,000 severance package, but the issue may be brought back up, board members have said.

It was unclear whether the decline in Erlanger's finances had to do with its relationship with another troubled hospital, Hutcheson Medical Center, as described in another Free Press article:

Despite a new board, new management and the infusion of a $20 million line of credit, a struggling North Georgia public hospital continues to lose money.

Erlanger at Hutcheson, formerly known as Hutcheson Medical Center, lost more than $9 million in the first five months of the 2012 fiscal year, which began in July. It lost the most -- $2.7 million -- in September.

Hutcheson board Chairman Corky Jewell could not be reached for comment last week.

The hospital's administrator, Debbie Reeves, and other management personnel were not in the office the week between Christmas and New Year's, according to spokeswoman Haley Johnson.

The publicly funded hospital in Fort Oglethorpe had been losing about $1 million a month, defaulted on a $35 million bond and laid off 75 employees in fiscal year 2011.

In May, Erlanger Health System took over management of the hospital and extended up to $20 million in credit to it.

Apparently inflated compensation to Hutcheson's CEO was also a subject of one of our posts from about a year ago. At that time, we wrote, "despite a major financial loss, lay-offs and service discontinuations, and a bond default," the CEO got "bonus and incentive compensation" in 2009.

So, to summarize, despite major financial problems, Hutcheson Medical Center's CEO got a bonus and incentive compensation in 2009. As its situation got worse, it was taken over in some sense by Erlanger Health System, whose CEO also got a bonus despite increasing financial problems in 2010. Thereafter, the finances of Erlanger really declined, its CEO announced his retirement, and still will collect a golden parachute.

Thus Erlanger Health System's golden parachute for its outgoing CEO symbolizes the anti-gravitational powers of executive compensation. While lavish executive pay is often justified by short-term financial results, health care executives seem to be able to just keep collecting more and more until they have to flee. Health care seems to more and more be run for the benefit of self-interested insiders.

Also, this case demonstrates how skeptical we ought to be of the breathless praise for health care executives and managers and the uncritical touting of their latest advances and initiatives.  (By the way, we posted here, just before it became apparent how badly Erlanger's finances were collapsing, about its breathless advertisement of a "new service excellence program" for Erlanger employees run by the Ritz-Carlton hotel chain.  One wonders whether the attention to the peripheral ahead of core responsibilities this denoted could have been one reason for the system's decline.) 

And we are just working our way up to our big case....

University of Chicago Medical Center

This story actually dates back to 2009, but was first revealed briefly in late 2011, in Becker's Hospital Review,

The other three highest-paid hospital CEOs in Chicago in 2010 include the following:
• James Madara, MD, and Ken Sharigian, University of Chicago Medical Center: $7.9 million
Note: This includes severance for Dr. Madara, who resigned in Oct. 2009. Mr. Sharigian served as the interim in 2010.

A little more detail came out in a side-bar to a story on executive compensation in higher education by the Chronicle of Higher Education:

James L. Madara, dean of the school of medicine and chief executive of the medical center, U. of Chicago
Total compensation: $7,038,944
Mr. Madara’s base salary was $1.3-million, and he received $2.5-million in severance pay.

There was also a hint of why this was so interesting:

Mr. [sic] Madara stepped down after seven years as dean and three as chief executive to return to the faculty. He resigned amid controversy over his management decisions, such as a plan to redirect medical-center patients to neighboring hospitals, according to local news reports.

A little digging shows there was more to it than that. Recall our recent post that discussed the "Urban Health Initiative," a program ostensibly meant to direct some patients, allegedly mainly poor patients, to more appropriate health care venues, allegedly away from the Emergency Department of the university medical center, and again allegedly to make room for patients who need and whose insurance can pay for more lucrative services.

By February, 2009, the Wall Street Journal reported that

In February, two high-ranking doctors quit their administrative posts to protest the plan, saying it could lengthen already long waiting times for patients who visit the ER.

In particular,

The two doctors who gave up their administrative posts in Chicago were Dr. Vanden Hoek, who stepped down as interim chief of emergency medicine, and pulmonology researcher Joe G.N. Garcia, who had been chairman of medicine. The doctors still can practice medicine at the hospital.

About a dozen other doctors from the emergency room and other departments had signed a letter of protest over the hospital administration's plan to reduce the number of beds available to emergency patients in the ER and other units.

Three months later, as reported by Chicago Business,

Some University of Chicago Medical Center faculty members are accusing CEO James Madara of putting hospital finances ahead of research and teaching.

A letter delivered to Dr. Madaar last month and signed by 76 faculty members asserts that, since adding the hospital CEO title in 2006, Dr. Madara has lost focus on his role as a dean of the Hyde Park medical center's vaunted research and academic enterprise. A preocccupation with hospital profits and an 'insular management style' have 'disenfranchised' the faculty, the letter says.

By that month, according to the Wall Street Journal,

More than 190 doctors at the University of Chicago Medical Center signed a letter to trustees protesting plans to reduce the number of beds available to emergency patients as 'unnecessarily risky' and a threat to patient safety.

The plan was put on hold by the university president a few days later. Dr Madara resigned in August.

So, somewhat like the case above, this involved a hospital system CEO who got a very large golden parachute after leaving under fire, not for declining revenue, but for his role in overseeing a program of questionable ethics, one possibly bad for patients, and having lost the confidence of some important proportion of his medical faculty.

He did not, however, go off quietly into the night. His next stop was Leavitt Partners (as noted in this AMA press release), founded by former President George W Bush administration Secretary for Health and Human Services James Leavitt.

As we noted here, Leavitt Partners advertises that it "advises clients that invest in health care and food safety." It does not publicize its client list, but that list apparently includes Alliance Health Networks, whose press release noted that Leavitt Partners "will help it expand its presence in the US health industry and beyond "(look here); and Connextions, Inc, whose press release noted that it would work with Leavitt Partners to " refine existing health insurance exchange models for federal and state governments, as well as private sector organizations that are navigating health care reform law," (look here.)  Mr Leavitt joined the board of Medtronic last year (look here). 

Then, however, he got back into the CEO business.  While still maintaining a role at Leavitt, in 2011, per the AMA release,

The American Medical Association (AMA) today named James L. Madara, M.D., as its new Executive Vice President and Chief Executive Officer. Dr. Madara will assume leadership of the nation’s oldest and largest physician group on July 1.

That news release noted his past positions,

the Thompson Distinguished Service Professorship and deanship at the University of Chicago Pritzker School of Medicine, where he was the longest serving Pritzker dean in the last 35 years. Subsequently, he added the responsibility of CEO of the University of Chicago Medical Center, bringing together the university’s biomedical research, teaching and clinical activities.

Perhaps not surprisingly, it did not mention the controversies at the medical center that preceded his resignation, nor his sizable golden parachute, nor his ongoing role at Leavitt Partners.

So, the American Medical Association claims to represent all US physicians and their values. It turns out that its current Executive Vice President and CEO is a former hospital system CEO who departed under fire with a golden parachute beyond any severance package a practicing or academic physician would dream about.  He also is a former and current consultant with a firm lead by one of our better recent examples of beneficiaries of the revolving door.  We have come a long, and the wrong way since the AMA asserted, "the practice of medicine should not be commercialized, nor treated as a commodity in trade." (See this post.)

This story is not just about the ridiculous compensation given to health care executives, and how this provides perverse incentives and suggests that many health care leaders have become insiders who put their self-interest ahead of the health care mission. This story is also about the connectedness of these insiders, and how they appear to control nearly every part of health care.

The Moral of the Stories

Maybe if I write this often enough, it will get some notice.... health care organizations need leaders that uphold the core values of health care, and focus on and are accountable for the mission, not on secondary responsibilities that conflict with these values and their mission, and not on self-enrichment. Leaders ought to be rewarded reasonably, but not lavishly, for doing what ultimately improves patient care, or when applicable, good education and good research. On the other hand, those who authorize, direct and implement bad behavior ought to suffer negative consequences sufficient to deter future bad behavior.

If we do not fix the severe problems affecting the leadership and governance of health care, and do not increase accountability, integrity and transparency of health care leadership and governance, we will be as much to blame as the leaders when the system collapses.